Article and method for controlling oral-originated systemic disease

ABSTRACT

Systems and methods for treating gingival tissue or oral biofilm includes applying to the gingival tissue (sulcus or periodontal pocket) a biofilm penetrating antimicrobial agent; removing the imbedded anaerobic bacteria from the gingival tissue following at least one applying of the antimicrobial agent to the gingival tissue; administering colloidal hydrogen peroxide gel to the gingival tissue following the removing of imbedded anaerobic bacteria; and cleaning the gingival tissue with a cleaning agent directly following the administering of the colloidal hydrogen peroxide gel for modifying the environment from anaerobic (diseased) to aerobic (healthy).

FIELD

The present disclosure relates to treatment of periodontal disease and,more specifically, to systems and methods for treating oral bacteriathat result in systemic disease in a patient.

BACKGROUND

The statements in this section merely provide background informationrelated to the present disclosure and may not constitute prior art.

Medical research has demonstrated a significant source of systemicdisease is related to specific oral bacteria, with special emphasis oncertain gram negative anaerobic bacteria that have been found associatedwith a variety of systemic inflammatory responses and appear tooriginate only in periodontal pockets and enter the bloodstream througha close proximity to the host circulatory system.

There are very few regions of the body which can readily be renderedconducive to the growth of anaerobic bacteria. Deeper periodontalpockets are one region that readily demonstrates infections that arepredominantly anaerobic, with gram-negative bacteria being the mostcommon isolates. The anatomic closeness of these biofilm periopathogensto the bloodstream can facilitate bacteremia and systemic spread ofbacterial products, components, and immunocomplexes (antigen/antibodyreactions, chemokines and cytokines).

It has been found that these oral periopathogens can become systemic.Research has demonstrated that bacteremia was observed in 100% of thepatients after dental extraction and in 70% after dental scaling.Mastication on infected gum tissues increases systemic bacterialendotoxins levels four-fold. Simple oral hygiene procedures, such asbrushing of the teeth, can increase the prevalence of bacteremia from 17to 40%. Research has also demonstrated that the dissemination of oralmicroorganisms into the bloodstream is common. In fact, it has beenfound that within less than 1 minute after an oral procedure, organismsfrom an infected site can reach the heart, lungs, and peripheral bloodcapillary system of a patient. These periopathogens can cause hostinjury (exotoxins and toxic bacterial products), inflammation (immunesystem—antigen/antibody reactions) and infections (bacteremia) in aperson. Periodontitis may affect the host's susceptibility to systemicdisease in three ways: by shared risk factors, by subgingival biofilmsacting as reservoirs of bacteria, and through the periodontium acting asa reservoir of inflammatory mediators.

It has also been found that controlling these periopathogens in themouth decreases systemic responses. Studies have evaluated periodontitisand C-reactive protein (CRP) levels in patients. For example, one studyevaluated three groups: (1) an untreated control group of 24 subjects;(2) a group of 21 subjects with a standard regimen of periodontaltherapy (SPT), consisting of subgingival mechanical instrumentation; and(3) a group of 20 subjects who had an intensive course of periodontaltreatment (IPT), consisting of SPT with adjunctive local delivery ofminocycline-HCl (Arestin®, Orapharma, Warminster, Pa., USA). The resultsof this study in both treatment groups identified a considerablereduction of periodontal lesions after therapy [60±27 (P<0.0001, N=21)and 60±23 (P<0.0001, N=20) mean differences tested by t test,respectively]. No changes were observed in the untreated controls.Similar results were found in the IL-6 markers. The report of that studyconcluded that periodontitis causes moderate systemic inflammation insystemically healthy patients because reducing the periodontal diseaseresulted in a reduction in the systemic inflammatory markers.

Periodontitis is an infection that can stimulate the liver to produceC-reactive protein (CRP) (a marker of inflammation), which in turn willform deposits on injured blood vessels. CRP binds to cells that aredamaged and fixes complement, which activates phagocytes, includingneutrophils. These cells release nitric oxide, thereby contributing toatheroma formation. It has been found that patients with adultperiodontitis have higher levels of CRP and haptoglobin than subjectswithout periodontitis. Both CRP and haptoglobin levels declinesignificantly after periodontal therapy. Additionally, in another studyof 153 systemically healthy subjects consisted of 108 untreatedperiodontitis patients and 45 control subjects, the mean plasma CRPlevels were higher in the periodontitis patients. Patients with severeperiodontitis had significantly higher CRP levels thanmild-periodontitis patients, and both had significantly higher levelsthan the controls. Another recent study evaluated the relationship ofcardiovascular disease and CRP into three groups of adults: i) hadneither periodontal nor cardiovascular disease, ii) had only one ofthese two diseases, and iii) had both of two diseases. In those withboth heart disease and periodontal disease, the mean level of CRP (8.7g/ml) was significantly different from that (1.14 g/ml) in controls withneither disease. It was also shown in that study that treatment of theperiodontal disease caused a 65% reduction in the level of CRP within 3months of treatment.

However, current methods to treat periodontal disease and the resultingeffects thereof suffer from a number of significant drawbacks and areoften ineffective in addressing the systemic effects of periodontaloriginated disease. Many of the systemic biomarkers decrease followingconventional oral disinfection, but these biomarker decreases are shortlived and return to abnormal elevated pre-treatment levels. The inventorof the present methods and systems has identified a significant need andbenefit to many patients in developing new procedures and systems thataddress the systemic effects of periodontal originated diseases.

SUMMARY

The inventor hereof has succeeded at designing methods and systems fortreatment of periodontal disease in patients that eliminate 99+% of theperiopathogens within 12 to 17 days of treatment, and the treatmentmethod becomes modified into the homecare method and is able to maintainthese improvements long-term. The method and system thus provides animproved effectiveness in reducing and/or eliminating resulting systemicdisease resulting therefrom. These include the application of atreatment plan or administration of steps to a patient suffering fromperiodontal disease for managing the most virulent anaerobic bacteria byaltering the environment from one conducive to disease (anaerobic) toone that is conducive to health (aerobic). As described herein, variousmethods and systems as described herein address the pathogens in asynergistic approach that provide steps that collectively have anunknown or unexpected benefit over the expected results of each of theseparate or individual steps. Generally, at least some of the methods asdescribed herein can be adapted for self-administration by the patientin a manner such that the oral environment can be permanently alteredfrom anaerobic aerobic, thereby not only eliminating the periopathogensbut also eliminating the environment in which they can return. In a likemanner, other medications can be used to modify the environment from oneof disease to one conducive to health. These can be monitored over timeand adjustments made as deemed necessary to promote a healthyenvironment.

According to one aspect, a method of treating oral biofilms includesapplying an antimicrobial agent to subgingival biofilm and gingivaltissue associated with the subgingival biofilm, altering an environmentassociated with the subgingival biofilm from anaerobic to aerobic andmodifying a protein or amino acid substratum associated with thesubgingival biofilm in a substantially irreversible manner. The methodalso includes removing imbedded aerobic and anaerobic bacteria from thegingival tissue following at least one application of the antimicrobialagent and administering colloidal hydrogen peroxide gel to a periodontalpocket associated with the subgingival biofilm and the gingival tissuein conjunction with or following the removing of imbedded anaerobicbacteria for facilitating further removal of imbedded anaerobicbacteria. The method further includes cleaning the gingival tissue witha cleaning agent directly following the administering of the colloidalhydrogen peroxide gel.

According to another aspect, a method of treating gingival tissueinfected with virulent bacteria includes the steps of applying to thegingival tissue an antimicrobial agent that is delivered and maintainedin a manner that controls, suspends or eradicates the function of thevirulent bacteria such as removing imbedded anaerobic bacteria from thegingival tissue following at least one application of the antimicrobialagent to the gingival tissue; administering colloidal hydrogen peroxidegel to the gingival tissue for further removing of imbedded anaerobicbacteria; and cleaning the gingival tissue with a cleaning agentdirectly following the administering of the colloidal hydrogen peroxidegel. According to some embodiments, it is now possible to recognize thedifferent bacteria or other micro-organisms in various regions of theperiodontium by PCR-DNA analysis and by other means. Specificantimicrobial agents that are best able to manage the micro-organisms inthe various regions can be site-specifically delivered to the variousregions to facilitate optimal microbial control and long-termmaintenance.

Further aspects of the present disclosure will be in part apparent andin part pointed out below. It should be understood that various aspectsof the disclosure may be implemented individually or in combination withone another. It should also be understood that the detailed descriptionand drawings, while indicating certain exemplary embodiments, areintended for purposes of illustration only and should not be construedas limiting the scope of the disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a cross-sectional view of a healthy tooth and gingival tissue.

FIG. 2A is a cross-sectional close-up photographic image of a marginalgingiva and tooth structure including a cementoenamel junction.

FIG. 2B is a line drawing representation of the photographic image ofFIG. 2A.

FIG. 3A is a close-up side photographic image of a tooth and associatedmarginal gingiva.

FIG. 3B is a line drawing representation of the photographic image ofFIG. 3A.

FIG. 4A is another close-up side photographic image of a tooth andassociated marginal gingiva.

FIG. 4B is a line drawing representation of the photographic image ofFIG. 3A.

FIG. 5A is a photographic microscopic image of an ulcer in a periodontalpocket.

FIG. 5B is a line drawing representation of the photographic image ofFIG. 5A.

FIG. 6 is a top plan view of a periodontal medicament delivery traysuitable for use with one or more embodiments of the present disclosure.

FIG. 7 is a side elevational view of a periodontal medicament deliverytray as worn by a patient for use in one or more embodiments of thetreatments of the present disclosure.

FIG. 8 is a side elevational view of upper and lower periodontalmedicament delivery trays as worn by a patient for simultaneoustreatment of both the upper and lower teeth and associated marginalgingiva according to some embodiments.

It should be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is notintended to limit the present disclosure or the disclosure'sapplications or uses. Before turning to the figures and the variousexemplary embodiments illustrated therein, a detailed overview ofvarious embodiments and aspects is provided for purposes of breadth ofscope, context, clarity, and completeness.

Periodontal disease has been found to be caused by planktonic bacteriaor bacterium and/or micro-organisms living in a biofilm. The mostvirulent of these bacteria have inherent properties that include beinggram negative-obligate anaerobes. These gram negative obligate anaerobicbacteria live in a biofilm in the deeper periodontal pockets aretherefore harder to reach or eliminate by conventional means. Thebacterial biofilm matrix composed of lipopolysaccharides,exopolysaccharides and other surface products as well as the endotoxins,exotoxins and other bacterial products cause signification immune systemresponses. In addition, these gram negative-obligate anaerobes have beenfound to invade the tissues causing localized and systemic inflammatoryresponses and to invade the individual cells and are then impervious thehost immune system. The anaerobes as part of a biofilm are almostimpervious to conventional treatments. Other micro-organisms, some ofwhich may not yet be discovered, can be impervious to existing treatmentmodalities and can cause local and systemic effects.

FIG. 1 shows a healthy tooth 10 with surrounding gum 12. The tooth 10includes a crown 14 having enamel 15, an inner composition of dentine 16that forms the root of the tooth 10, and cementum 18 that covers theouter surface of the lower portions of the tooth 10 below the enamel 15.A cementoenamel junction (CEJ) 20 is defined as the intersection of thelower end of the enamel 15 and the start of the cementum 18. As shown,the gum 12 includes gingiva 22 that has gingival tissue 24 having aportion referred to as marginal gingiva tissue 26, and attached gingivatissue 28, the two portions generally being separated by the CEJ 20. Thegum 12 forms a gingival sulcus 30 at the intersection with the tooth 10.An epithelium 32 covers the lower portions of the enamel 15 above theCEJ 20 such that the cementum 18 is not exposed in a healthy tooth 10 asshown. Connective tissue 34 of the gingiva tissue 24 is adjacent to theepithelium 32 (this portion referred to as the junctional epithelium 33)and includes a bed of capillaries, hereinafter referred to as acapillary bed 36, and alveolar fibers 38. An alveolar bone 40 has analveolar crest 42 that extends nearly to the CEJ 20 to form a deepsocket (not shown) for the tooth 10. Biofilm 44 generally forms to coatthe outer surface of the enamel 15. FIGS. 2A and 2B illustrates aclose-up of an environment 46 about the CEJ 20 including the location ofthe junctional epithelium 33 between the enamel 15 and the connectivetissue 34 that includes the capillary bed 36.

FIGS. 3A and 3B and 4A and 4B illustrate environment 46 in additionaldetail. From these detailed illustrations, that where epithelium 32exists, as shown at “A” in FIG. 3B, there is only 1 or 2 cellsseparating the interface with the outer surfaces of the tooth 10 thatcan be exposed when the gingival sulcus 30 widens during infection. Whenthe bacteria proliferate in this region the tissue is modified so thereis no epithelium 32 present, shown at “B” in FIGS. 4A and 4B. Theexposure of the underlying connective tissue 34 and capillary system 36in direct contact or at least very close proximity of any pathogenspresent in the gingival sulcus 30 or, a periodontal pocket (not shown)associated therewith, provides access to the host circulatory system andthus systemic involvement is possible.

While not shown in the figures, in a diseased tooth 10 such as with onehaving an inflammation from periodontal disease, the junctionalepithelium 32 moves apically (or toward the apex of the root), exposesthe cementum 18 and enlarges the sulcus 30 thereby creating a pocket(not shown). Facultative anaerobes modify this environment 46 from onewith minimal oxygen to an anaerobic environment conducive to developmentof virulent anaerobic periopathogens. An ulcer 48, such as shown undermagnification in FIGS. 5A and 5B, can form in the periodontal pocket. Ascan be seen in this illustration, the ulcer 48 of the periodontal pocketcan be directly adjacent to, and/or in contact with the capillary bed 36of the connective tissue 34. As the inflammation spreads, the alveolarbone 40 is destroyed. This increases the mobility of the tooth 10 andcan lead to loss of the tooth 10 (not shown in FIG. 5A or 5B).Additionally, this enlarging reservoir (enlarged sulcus 30 and pocket)serves as a source of bacteria, bacterial products and host inflammatoryresponses that can become systemically involved via the close proximityto the host bloodstream.

In one embodiment, a method of treating gingival tissue, biofilm, suchas may be infected with a periodontal disease, includes applying to thesubgingival biofilm and/or gingival tissue an antimicrobial agent. Forexample, an antimicrobial agent that is capable of modifying theenvironment from an anaerobic situation to an aerobic one that canaddress the removing of imbedded anaerobic bacteria from the gingivaltissue. The method can also include administering colloidal hydrogenperoxide gel to the gingival tissue for aiding in altering theenvironment from anaerobic to aerobic and thereby also addressing theimbedded anaerobic bacteria; and cleaning the gingival tissue with acleaning agent directly following the administering of the colloidalhydrogen peroxide gel or other agents that may facilitate theantimicrobial or cleansing process. Specific antimicrobial agents thatcan best control specific biofilm bacteria can be applied to thoseregions where the specific microbes are found so as to best control thepathogen population. These site-specific medications can be modified asalterations in the biofilm matrix are determined by PCR-DNA analysis orby other means.

The method provides for the application or delivery of an antimicrobialagent, such as hydrogen peroxide by way of example, which can bedelivered into the periodontal pocket and maintained in the pocket for aprescribed period of time sufficient to kill the periopathogens and toalter the environment from one conducive to disease (anaerobic) to oneconducive to health (aerobic). In some embodiments, such antimicrobialagent is applied using a periodontal medicament delivery tray availableto the patient or as procured during the first step, where applicable.Additionally, where an acute case is diagnosed, the application of theantimicrobial agent also follows the modification of the environment asprovided in the altering process. Examples of currently knownantimicrobial agents suitable for use and include Actisite, Atridox,Periochip, Arestin, Perio Tray™/colloidal hydrogen peroxide,Electrolyzed water, Alcohol, Iodine, and Hydrogen Peroxide.

As noted, the antimicrobial agents can be modified and/or customized inthe biofilm matrix by PCR-DNA analysis or by other means. For example,during either an initial diagnosis procedure of a patient or where allor a portion of an affective region fails to favorably respond to ageneral broad-spectrum or another antimicrobial agent, a sample of thebacteria within the periodontal pocket can be obtained and forwarded toa lab for determining the particular pathogens. A sample can be takenfrom an attending medical practitioner by using any suitable means,including, by way of example, a paper point inserted into theperiodontal pocket to be tested. After the diagnostic procedure iscompleted and the particular bacteria present in the periodontal pocketis determined, the antimicrobial agent is selected or customized, suchas by creation of a blend or cocktail of agents or medicaments, forspecifically controlling the determined bacteria. Such a process can beinitiated at the beginning of a treatment as described herein, or can beperformed during or with one or more of the other processes to aid inthe overall treatment of the patient.

Referring to FIGS. 6, 7 and 8, a form-fitted flexible periodontalmedicament delivery tray 50, is adapted for applying one or more of themedicaments 52 described in the various methods in accordance withvarious embodiments. More specifically, tray 50 is of a suitable softplastic elastomeric or other suitable material which is molded in placeto the patient's teeth so as to form a dental arch recess 54 whichconforms closely to a patient's teeth and which firmly and closely fitsin place on the patient's teeth. Tray 50 is shown to be a full archtray, but those skilled in the art will recognize that a partial archtray or a dual arch tray may be used, if desired.

In some embodiments, the patient can deliver the antimicrobial agent oragents to continue to manage the affected environment to kill orcontinue to kill the obligate and facultative anaerobes and/or preventtheir formation in a general or a site specific manner. The applicationof the antimicrobial agent(s) or other medicaments beneficial to healthcan be provided as a long term treatment of which the patientself-applies at home. It can also be extended as needed to control anychronic aspects of the periodontal disease and to maintain anenvironment conducive to health that is aerobic and further inhibits thegrowth and re-growth of anaerobic bacteria.

The applied antimicrobial agent can be any antimicrobial agent that issuitable for managing the microorganisms and for maintaining a tissueenvironment that is conducive to health. This can be a medicament thatis aerobic and inhibits the growth and re-growth of anaerobic bacteriaor any other medicament conducive to a favorable and healthy situation.For example, this can include, but is not limited to hydrogen peroxide.Of course, it should be understood that the application of theantimicrobial agent can be a single application or can be multipleapplications that can be generally delivered or site specificallydelivered that are repeated more than once and can, in some embodiments,be repeated on a periodic basis. Additionally, such application of theantimicrobial agent can be provided several times each day or otherwiseadjusted to the frequency as may be directed or performed by a dentistor health care professional.

It should be noted that the application of the antimicrobial agent canbe performed in any suitable manner. In one embodiment, a tray adaptedfor directly applying a medicament to the gums about the teeth, thegingival tissue, is used. For example, the antimicrobial agent can befilled or at least partially filled into a cavity of periodontalmedicament delivery tray. The tray can then be attached or applied tothe gums and about the associated teeth for application of themedicament to the area to be treated. Additionally, as shown in FIG. 6,only one of the upper or lower teeth and associated gingival tissue canbe treated or, as shown in FIG. 7, both the upper and lower teeth andassociated gingival tissue can be treated simultaneously.

Following or during a portion of application of the antimicrobial agentand/or the modification of a protein or amino acid substratum associatedwith the subgingival biofilm and/or the environment, the method providesfor the removal of imbedded anaerobic bacteria from the gum and/oraffected connective tissue. Certain of the oral bacteria possess thecapability of host cell invasion directly and cause the host cells toact in ways different from normal non-infected cells. These abnormalcells must be removed by any suitable procedure including surgery suchas electro-surgery, scaling and root planning laser surgery orconventional “cold steel” surgery or any other means available forremoving imbedded micro-organisms from the host cells/gum tissue. Thisprocess removes the imbedded pathogenic bacteria that have the potentialto invade the host cells of the host tissue. The surgical removal isoften required as these imbedded pathogenic bacteria are oftenimpervious to most other treatment methods. While such pathogenicbacteria are controlled and/or killed in the procedures of applying anantimicrobial agent, altering the environment, and/or modifying aprotein or amino acid substratum, the removal of the imbedded pathogenicbacteria is performed for providing a healthy and clean environment.Such removal can be by any suitable method, and can include physicalremoval such as by surgery. However, it should be noted that it has beendemonstrated that subgingival bacteria remaining after conventionaltreatments have the potential to re-colonize to pretreatment levels ifnot property maintained, thus fostering the re-growth of obligateanaerobes. For example, in one known study, oral biofilm was evaluatedbefore and after conventional periodontal therapy. Samples taken beforeperiodontal therapy harbored more bacteria than after therapy. Samplestaken after periodontal therapy had the same species as were presentbefore treatment, but in a reduced number both sets of biofilms grew ata similar rate. The treatments as described here can provide for theremoval of the subgingival bacteria that remains after conventionalperiodontal treatments as they have the potential to re-colonize topretreatment levels if the corrected environment is not otherwiseproperly maintained.

Following the removal process, a colloidal hydrogen peroxide gel, orsuitable substitutes and equivalents, is applied to the sulcus such asby using a periodontal medicament delivery tray, for example sometimesreferred to herein as Perio Tray™ treatments. Examples, of suchavailable application methods include Perio Chip, Arestin, PerioTray/Perio Gel, Atridox, and Actisite. Of course those skilled in theart will recognize that there are other current and future suitablealternatives, each of which is considered to be within the scope of thepresent disclosure. Additionally, it should be understood that thisprocess may be provided as instructions to a patient for theirself-care.

These treatments facilitate healing of the affected tissue by providingor continuing to maintain the modified environment and to continue toprohibit the growth of pathogenic bacteria. In this manner, the gainsmade in prior processes are maintained and the growth of any additionalpathogenic and especially anaerobic bacteria within the gums issuppressed. This application of the colloidal gel, such as hydrogenperoxide gel, to the sulcus and/or periodontal pocket can furtherinhibit the development of the obligate anaerobic population within thetreated environment and can foster healing of the host connectivetissue. As one example, a Perio gel at 1.7 percent from Perio Pharma hasbeen evaluated as to efficacy in management of oral periopathogens in ananaerobic environment and is one example of a suitable treatment forthis process.

The scope and magnitude of the disease, the depth of the periodontalpocket and the colonization of the pathogenic and especially pathogenicbacteria determine the frequency and duration of treatments.Modifications in the environment render a change in the bacterial floraand changes in the host response, which will result in a modification inthe frequency and duration of medicament usage.

The utilization of a periodontal medicament delivery tray such as thePerio Tray™ in this administration of the colloidal hydrogen peroxidegel, or suitable substitutes, can include, but is not limited to,filling at least a portion of a periodontal medicament delivery tray(could be the same or a different one than identified above) with thehydrogen peroxide gel and attaching the tray about the gingival tissuein such a manner as to direct the medicaments to the oral biofilm. Ofcourse it should be understood to those skilled in the art that theadministering of the colloidal hydrogen peroxide gel to the gingivaltissue can be repeated more than once and site-specific medications canbe delivered for optimal control of certain pathogens. For example, theadministering can be repeated on a periodic basis. Additionally, theadministration can be provided subgingival by the patient several timeseach day or otherwise to adjust the general or site-specific dosage orfrequency of medicament administration as may be directed by a dentistor health care professional, such as may be required in accordance withthe diseased status and also changes in the status of the disease ashealing occurs.

The method also includes application of a cleaning agent to the gingivaltissue, gums and/or the tooth of the affected area for removal of anydead bacterial cells or the protein layer that may be present. This canbe any suitable cleaning agent and use any suitable cleaning method. Inone embodiment, this includes use of a sonic or ultrasonic cleaningagent using a sonic cleaning device or system that is applied to theaffected area generally following the application of a colloidalmedicament directly to the sulcus. The inventor hereof has found thatthe process of cleaning the gingival tissue following the above stepsprovides for an improved and more effective removal of the protein layerand the bacteria attached to this layer by the sonic cleaning agent.Additionally, this order of processes was found in some embodiments todisrupt the protein layer that improves the effectiveness of the soniccleaning agent in removing the protein layer. Such removal can beprovided before the pathogenic bacteria can repopulate the toothsurface. Additionally, the follow-up cleaning process can create acontinued oxygen rich environment, for continued modifying theenvironment where the facultative anaerobic bacteria and the obligateanaerobes grow. In this manner, the biofilm is modified from oneconducive to disease to one that is conducive to the growth of bacteriathat can live in harmony with the host, e.g., commensal bacteria.

In some embodiments as described herein, the facilitation of cleaningoccurs through a modification of the environment. Oral bacteria are notable to bind to oral structures directly, but require a protein, aminoacid layer on which to attach. Initially aerobic bacteria colonize theregion, but if the region becomes conducive to the formation offacultative anaerobic bacteria, the region can become anaerobic. One ofthe initial steps in treatment and cleansing must therefore be amodification of the protein or amino acid layer. This is accomplishedthrough a timed occurrence delivery and the action of colloidal hydrogenperoxide as it permanently modifies the protein layer and by alteringthe amino acids in a permanent manner (cleaves hyaluronic acid, convertshistadine to alanine and asparagine to aspartate) whereby the proteinlayer or amino acid layer is disrupted and is more easily removed bymechanical or sonic means.

Of course, it should be understood that the cleaning of the gingivaltissue can be repeated two or more times and in one embodiment, is atleast repeated following each of any repeated administering of thecolloidal hydrogen peroxide gel. Such cleaning can be provided by thepatient several times each day or otherwise to the frequency as may bedirected by a dentist or health care professional. Additionally, suchcleaning can be directed or provided as instructions from the medicalprovider to the patient for self-care.

The protein and amino acid modification alters the substrate such thatmechanical and sonic cleaning agent, by way of example, a sonictoothbrush that applies a cleaning agent such as a sonic cleaning agentto the gingival tissue.

There are multiple potential cleaning agents readily available thatinclude dentifrices, mouth rinses, tooth paste, oral irrigants and othercommercial products.

It should also be noted that the above processes can first begin with anexamination using suitable methods to evaluate the presence and effectsof periodontal disease. During such examination process, the requirementof one or more medicament delivery methods is evaluated and theirsequence in utilization is determined. For example, in one embodiment,it may be determined that a periodontal medicament delivery tray may bean applicable method for delivery of medicaments for the treatments asdescribed herein. For example, a Perio Tray™ may be the preferreddelivery system. In such cases, the fabrication of a tray may beinitiated during an early examination and prior to application of theabove other processes of the method. This can be at any time prior tothe remaining treatment processes. Currently such periodontal medicamentdelivery trays often take some time to be fabricated, especially if oneis not currently available for the patient's use. However, there may besome instances where a periodontal medicament delivery tray may alreadybe available to the patient. In such instances, this portion of theprocess may be skipped especially as to obtaining the impression and thefabrication of the periodontal medicament delivery tray. At other times,it may be conducive to initiate conventional periodontal treatments;such as scaling and root planning, surgery, laser surgery or localizeddelivery of antibiotic or antimicrobial agents to the infected area(Arestin, Perio Chip, Atridox, Actisite, etc.)

In some instances where a Perio Tray™ is preferred, this can includefabrication of the periodontal medicament delivery tray such aspreparing a female impression of the patient's teeth and adjacent gumsthat are the affected gums, making a male model of the patient's teethand adjacent gums from the female impression, and fabricating the trayfrom the male model. In one embodiment, this also includes forming araised seal in a location such that a resilient material is formed as aseal against the patient's adjacent gums. The seal is formed withminimal contact to the patient's teeth, but in a manner to directmedications to the source of the infection.

In the situation where a patient is identified as suffering of anobligate anaerobic infection (that is an organism that survives only inthe absence of oxygen, e.g., obligate anaerobe), the method provides forthe direct application of an aerobic colloid applied directly into thesulcus or periodontal pocket. In a situation where a patient is found tosuffer with a specific pathogen dominated disease, direct medicationscan be delivered to that specific site to assist in controlling theinfectious agent. The medicament should be able to readily penetrate thebiofilm and biofilm matrix and may contain an aerobic solution, such asa hydrogen peroxide colloid by way of example that is held in the sulcusfor a period of time that is long enough to modify the environment froman anaerobic one to an oxygen rich aerobic one, or it may be a morebacteria-specific agent that can optimize microbial control. In a likemanner, any medicament can be applied to manage the microbes and providean environment conducive to health.

Colloidal gels as described herein can include, but are not limited toPerio Gel from Perio Pharma, Peroxyl from Colgate Palmolive, andCarbamide peroxide gel, by way of examples.

The period of time can vary based on the conditions of the periodontaldisorder but is generally from about 10 to 15 minutes.

The method of direct application can vary in accordance to the scope andmagnitude of the disease, even to the point of microbial-specificmedication delivery to specific sites of the infection. Gingivitistreatments usually can be rendered from one to three times a day andlong-term maintenance can be obtained with daily or twice dailyapplications. Periodontitis treatments can be rendered from two to sixtimes a day, modified as healing occurs and maintained with long-termusage of two or more times a day as determined by the patient'sconditions and healing. Any region that requires site-specific treatmentcan be administered as the micro-organisms are recognized to requirespecific considerations.

The various methods of direct application of this medicament caninclude, but is not limited to, oral rinses, application throughbrushing or flossing, direct application and through usage of the PerioTray™ system and special microbial-specific medications. Oral rinses arenot generally deliverable into the periodontal pocket as rinses areunable to overcome crevicular flow. Similarly, brushing and flossing donot typically penetrate greater than 3 mm into the periodontal pocketand even then crevicular flow dilutes the medicaments. In addition, thebacteria are so small and reproduce so rapidly that mechanical removalalone has proven ineffective in controlling them. Likewise, directmedicament applications into the periodontal pocket are unable tomaintain a sufficient amount of medicament over an extended period oftime and are not renewable to alter the environment and maintain amodified environment sufficient for health and healing. As such, aperiodontal medicament delivery tray such as the Perio Tray™ system hasbeen found to provide for direct application of the medicament in manysituations and applications. This can encompass general medicamentdelivery or site-specific micro-organism specific medicaments.

In some embodiments, the direct application of the aerobic colloid aperiodontal medicament delivery tray such as the Perio Tray™ can createan oxygen rich environment that kills the obligate anaerobes containedtherein and kills the facultative anaerobes (a facultative parasite canlive independently of its usual host as they can live off the wasteproducts of other bacteria) as well as aerobic bacteria in theassociated biofilm. This includes killing facultative anaerobesincluding bacteria that can live in both aerobic and anaerobicenvironments. By killing the facultative anaerobes, they are preventedfrom modifying the environment to one where the most virulent obligateanaerobes are able to function. As such, this process that includeskilling these facultative anaerobes in the biofilm in addition to thethen present obligate anaerobes (including those that cause decay) canprovide for inhibiting the future growth of obligate anaerobes inaddition to killing those currently present. It would also be possibleto introduce specific beneficial bacteria into the regions as healingoccurs to compete with the pathogenic bacteria and promote healing and ahealthy environment.

The medicament, such as the colloidal hydrogen peroxide gel, by way ofexample, can in some situations be limited to treatments where there isan acute infection. As such, the administering of the colloidal hydrogenperoxide gel can be provided in the acute phase treatments to addressthe virulent pathogens and to change the environment from one conduciveof virulent pathogen development to one that is not conducive thereof.However, the administering process may not be applied in someembodiments of the method. This particular process step can be appliedfollowing examination and prior to the other steps of the method, suchas, for example, during and/or in parallel to the fabrication orprocurement of a suitable periodontal medicament delivery tray for theparticular patient. It is also understood that site-specificmicro-organism-specific medications could be used as deemed appropriateby the health care provider.

It should also be understood that the administering process can bepracticed once or can be repeated two or more times as may be needed ordesired such as to modify the environment to one that is conducive tothe growth of more commensal bacteria that are not pathogenic, e.g., anoxygen rich aerobic environment. It is also possible to introducecommensal bacteria into the sulcus or periodontal pocket by directapplication means. It should also be understood that such directapplication of a medicament can be provided by the health care provideror by the patient several times each day or otherwise adjusted to thefrequency and length as may be directed by a dentist or health careprofessional.

As described herein, a periodontal medicament delivery tray may be anysuitable tray for direct applicant of a medicament about the teeth andgums. One example, of such is the Perio Tray™ as described in the U.S.Pat. No. 6,966,773, as issued to the inventor hereof. As describedherein, such periodontal delivery trays, or variations thereof, can beworn by the patient for the purpose of controlling the oralperiopathogens that are associated with specific systemic diseasefactors and conditions.

The methods and systems as described herein address the pathogens in asynergistic approach that provides steps that collectively have anunknown or unexpected benefit over the expected results of each of theseparate or individual steps.

Literature in the medical and dental journals demonstrate that beingable to control oral periopathogens have effects on systemic situations.Various embodiments of the present systems and methods can provide forthe control of oral periopathogens that have effects on systemicsituations, for example, scaling and root planning decrease C-reactiveprotein and lower patient lipid levels, decreases patients glycosylatedhemoglobin and decreases the incidence of premature and low birth weightbabies.

In a study by the inventor hereof, patients treated with the methods andsystems as described herein, resulted in a significant reduction intheir CRP levels. In fact, the inventor has found that 29 of 32 patientswere successful at maintaining these significantly reduced CRP levelsand such levels were normal for up to one year following treatment. Itshould be noted that of the patients that had elevated levels, each ofthe patients had a systemic reason (infection, gastroenteritis, etc.)for the elevation. The pilot program only included treatment to controlthe periopathogens and as such was successful at documenting thedecrease in the systemic CRP involvement (inflammation, injury orinfection).

Additionally, the inventor hereof has also documented using a scanningelectron microscopy that the periopathogens can be reduced by 99.98%within 12 to 17 days of the start of the treatment as described herein.These results can continue to control the periopathogens long-term inpatients who use of the methods as described herein.

Patient's C-reactive protein systemic levels decreased when treated withthe system and oral methods as described in this present disclosure. Itis also expected that other systemic markers changes will result fromthe resulting control of the periopathogens.

One embodiment of a pilot program as described herein had been heldwherein the C-reactive protein changes in patients have been measured.The results of this pilot program resulted in 29 of 32 patients havingtheir C-reactive protein levels return to normal. C-reactive protein isassociated in the medical literature with cardiovascular problems,Alzheimer's disease, Type II diabetes and pre-term and low birth weightbabies and other systemic inflammatory changes.

This can provide the benefit over the prior practices and methods assome embodiments of the current method can provide for controlling oneof the causes of systemic inflammation, thereby controlling systemicimprovements in a patient. In addition, in various embodiments thecontrol of the bacteria that causes decay can decrease the incidence ofnew or recurrent decay and site-specific medication applications arepossible when needed.

As used herein, a biofilm is intended to refer to any complex structureof a mixed bacterial colony adhering to surfaces that are regularly incontact with oral fluids, consisting of colonies of bacteria and usuallyother microorganisms such as yeasts, fungi, and protozoa that secrete amucilaginous protective coating in which they are encased. Thesebiofilms can form on solid or liquid surfaces as well as on soft tissuein living organisms, and are typically resistant to conventional methodsof disinfection. Dental plaque is an example of a biofilm. Biofilms aregenerally pathogenic in the body, causing such diseases as cysticfibrosis and otitis media.

An anaerobe as used herein is an organism, such as a bacterium, is onethat can live in the absence of atmospheric oxygen, e.g., does notrequire air or free oxygen to live. Pathogenic bacteria as used hereindefines any microorganisms that reside in a parasitic or harmful mannerand causes infectious, injurious, inflammatory or other deleteriouseffects on the host. Additionally, while bacteria such as anaerobicbacteria is described in this disclosure, such reference is by way ofexemplary embodiment. It should be understood that such references tobacteria can similar include or alternatively apply to micro-organisms,wherein micro-organisms are fully within the scope of the presentdisclosure.

As used herein, commensal refers to a symbiotic relationship in whichone species is benefited while the other is unaffected or an organismparticipating in a symbiotic relationship in which one species derivessome benefit while the other is unaffected.

When describing elements or features and/or embodiments thereof, thearticles “a”, “an”, “the”, and “said” are intended to mean that thereare one or more of the elements or features. The terms “comprising”,“including”, and “having” are intended to be inclusive and mean thatthere may be additional elements or features beyond those specificallydescribed.

Those skilled in the art will recognize that various changes can be madeto the exemplary embodiments and implementations described above withoutdeparting from the scope of the disclosure. Accordingly, all mattercontained in the above description or shown in the accompanying drawingsshould be interpreted as illustrative and not in a limiting sense.

It is further to be understood that the processes or steps describedherein are not to be construed as necessarily requiring theirperformance in the particular order discussed or illustrated. It is alsoto be understood that additional or alternative processes or steps maybe employed.

What is claimed is:
 1. A method of treating oral biofilms comprising:determining a facultative anaerobic bacteria pathogen present within asubgingival biofilm associated with the oral biofilm, wherein thesubgingival biofilm has a protein layer and an amino acid; applying anantimicrobial agent to a subgingival portion of a tooth and a gingivaltissue surrounding the tooth, the applying of the antimicrobial agentpenetrating the subgingival biofilm and the gingival tissue associatedwith such subgingival biofilm wherein the determining and applying arerepeated a plurality of times until an environment associated with thesubgingival biofilm is altered from anaerobic to aerobic, killing thedetermined facultative bacteria pathogen, modifying the protein layer,and altering the amino acid associated with the subgingival biofilm tocleave hyaluronic acid, convert histadine to alanine and asparagine toaspartate; surgically removing the determined facultative anaerobicbacteria from the gingival tissue that is remaining and that is imbeddedfollowing the applying of the antimicrobial agent that obtains theaerobic environment associated with the subgingival biofilm, the killingof the determined facultative bacteria pathogen, the modification of theprotein layer and the altering of the amino acid; administering acolloidal hydrogen peroxide gel to a periodontal pocket associated withthe subgingival biofilm and the gingival tissue in conjunction with orfollowing the surgically removing of at least a portion of the imbeddedanaerobic bacteria to chemically remove a further portion of theimbedded anaerobic bacteria not removed during the prior surgicalremoving process; and cleaning the gingival tissue with a cleaning agentdirectly following the administering of the colloidal hydrogen peroxidegel.
 2. The method of claim 1 wherein the process of applying theantimicrobial agent is applying an oxygenating agent.
 3. The method ofclaim 2 wherein the applied antimicrobial agent is selected from thegroup consisting of Perio gel, hydrogen peroxide, Peroxyl, carbamideperoxide, whitening and bleaching gels.
 4. The method of claim 1 whereinthe applying of the antimicrobial agent is on a periodic basis.
 5. Themethod of claim 1 wherein applying the antimicrobial agent includesfilling at least a portion of a periodontal medicament delivery traywith the antimicrobial agent and attaching the tray about the gingivaltissue.
 6. The method of claim 1 wherein the process of surgicallyremoving imbedded anaerobic bacteria includes a process selected fromthe group consisting of electro-surgery, scaling and root planning lasersurgery, and cold-steel surgery.
 7. The method of claim 1 whereinsurgically removing the imbedded anaerobic bacteria includes removingthe facultative anaerobic bacteria from a periodontal pocket located inclose proximity to a circulatory system of the gingival tissue.
 8. Themethod of claim 1 wherein administering includes applying the colloidalhydrogen peroxide gel to a sulcus or a periodontal pocket on thegingival tissue.
 9. The method of claim 8 wherein the process ofadministering maintains the aerobic environment obtained during theapplying process.
 10. The method of claim 1 wherein administeringincludes filling at least a portion of a periodontal medicament deliverytray with the colloidal hydrogen peroxide gel and attaching the deliverytray about the gingival tissue associated with the periodontal pocket.11. The method of claim 1, further comprising repeating theadministering of the colloidal hydrogen peroxide gel following theremoving of imbedded anaerobic bacteria on a periodic basis formaintaining an environment conducive to only aerobic bacteria.
 12. Themethod of claim 10, further comprising repeating the cleaning of thegingival tissue with a cleaning agent directly following each repeatedadministering of the colloidal hydrogen peroxide gel.
 13. The method ofclaim 1 wherein the cleaning includes using at least one of a mechanicaland a sonic toothbrush for applying a cleaning agent to the gingivaltissue.
 14. The method of claim 1 wherein the cleaning agent is areadily available commercial oral hygiene cleaning agent selected fromthe group consisting of dentifrices, mouth rinses, tooth paste, and oralirrigants.
 15. The method of claim 1 wherein the cleaning agent isapplied to a sulcus of the gingival tissue by using a periodontalmedicament delivery tray adapted for establishing an environment ofhealth and healing and reduces the environment of disease and infection.16. The method of claim 15 wherein the process of cleaning includesusing a sonic cleaning device with the cleaning agent that is suitablefor use with said sonic cleaning device.
 17. The method of claim 1,further comprising repeating the cleaning of the gingival tissue with acleaning agent on a periodic basis following the administering of thecolloidal hydrogen peroxide gel.
 18. The method of claim 1, furthercomprising preparing a periodontal medicament delivery tray configuredfor at least one of applying an antimicrobial agent and administeringcolloidal hydrogen peroxide gel.
 19. The method of claim 18, furthercomprising performing an evaluation examination of the patient, whereinpreparing the periodontal medicament delivery tray is initiated duringthe performing of an evaluation examination, wherein preparing theperiodontal medicament delivery tray includes fabricating the deliverytray including: preparing a female impression of a patient's teeth andadjacent gums associated with the oral biofilms being treated; making amale model of the patient's teeth and adjacent gums from the femaleimpression; and fabricating the delivery tray from the male model. 20.The method of claim 19 wherein preparing the periodontal medicamentdelivery tray further includes forming a raised seal in a location suchthat a resilient material is formed as a seal against the patient'sadjacent gums, said seal formed so as to have no contact with thepatient's teeth.
 21. The method of claim 1, in addition to the applyingof the antimicrobial agent the plurality of times to the subgingivalportion of the tooth and the gingival tissue surrounding the tooth toobtain the aerobic environment and in addition to the administering ofthe colloidal hydrogen peroxide gel to the periodontal pocket associatedwith the subgingival biofilm, further comprising applying an aerobiccolloid directly to a sulcus area associated with the tooth and gingivaltissue being treated following the applying that obtains the aerobicenvironment, the removal of the imbedded anaerobic bacteria by thesurgical removing and the administering of the colloidal hydrogenperoxide to the periodontal pocket and the cleaning, wherein theapplying the aerobic colloid directly to the sulcus area inhibits thefuture growth of obligate anaerobes on the tooth and gingival tissue.22. The method of claim 21 wherein the aerobic colloid is a hydrogenperoxide colloid or a colloid selected from the group of oxygenationmedicaments consisting of hydrogen, carbamide peroxide or other agentscommercially available.
 23. The method of claim 1, further comprising,following the applying of the antimicrobial agent to obtain the aerobicenvironment, the surgically removing the portion of the imbeddedanaerobic bacteria from the gingival tissue, and the administering ofthe colloidal hydrogen peroxide to the periodontal pocket, directlyapplying a commensal bacteria into the sulcus or a periodontal pocketassociated with the gingival tissue to re-colonization the sulcus or theperiodontal pocket with the commensal non-harmful bacteria.
 24. Themethod of claim 1, further comprising providing instructions to apatient including the process of administering and cleaning for enablingthe patient for performing the administering and the cleaning.
 25. Themethod of claim 1, further comprising selecting the antimicrobial agentto be applied for each of the plurality of times of applying anantimicrobial agent, wherein the selecting is from a plurality ofantimicrobial agents, wherein selecting includes prior to at least oneof the one or more times of applying the antimicrobial agent,determining a bacteria present in the subgingival biofilm or thegingival tissue associated with the subgingival biofilm.
 26. A methodfor treating gingival tissue comprising: determining a facultativeanaerobic bacteria pathogen present within a subgingival biofilmassociated with the gingival tissue, wherein the subgingival biofilm hasa protein layer and an amino acid; applying an antimicrobial agent to asubgingival portion of a tooth and a gingival tissue surrounding thetooth, the applying of the antimicrobial agent penetrating thesubgingival biofilm and the gingival tissue associated with suchsubgingival biofilm on a periodic basis, said applying includes fillingat least a portion of a periodontal medicament delivery tray with theantimicrobial agent and attaching the tray about the gingival tissue,the determining and applying being repeated until an environmentassociated with the subgingival biofilm is altered from anaerobic toaerobic is obtained, the determined facultative bacteria pathogen iskilled, the protein layer is modified and the amino acid is altered tocleave hyaluronic acid, convert histadine to alanine and asparagine toaspartate; surgically removing the determined facultative anaerobicbacteria from the gingival tissue that is remaining and that is imbeddedfollowing the applying of the antimicrobial agent that obtains theenvironment associated with the subgingival biofilm is the aerobicenvironment associated with the subgingival biofilm, the killing of thedetermined facultative bacteria pathogen, the modification of theprotein layer and the altering of the amino acid; and providinginstructions to a patient including instructions for administering acolloidal hydrogen peroxide gel to a periodontal pocket associated withthe subgingival biofilm and the gingival tissue in conjunction with orfollowing the surgically removing of at least a portion of the imbeddedanaerobic bacteria to chemically remove a further portion of theimbedded anaerobic bacteria not removed using the prior surgicalremoving process and cleaning the gingival tissue with a cleaning agentdirectly following the administering of the colloidal hydrogen peroxidegel.
 27. The method of claim 26, further comprising: selecting theantimicrobial agent to be applied for each application of the applyingstep from among a plurality of antimicrobial agents, wherein selectingincludes determining a bacteria present in the subgingival biofilm orthe gingival tissue associated with the subgingival biofilm.
 28. Themethod of claim 1, further comprising, following the process ofdetermining and prior to the applying, selecting the antimicrobial agentthat is capable of readily penetrating the subgingival biofilm and abiofilm matrix associated with the oral biofilm.
 29. The method of claim26, further comprising, following the process of determining and priorto the applying, selecting the antimicrobial agent that is capable ofreadily penetrating the subgingival biofilm and a biofilm matrixassociated with the oral biofilm.
 30. The method of claim 26, furthercomprising, following the applying of the antimicrobial agent to obtainthe aerobic environment, the surgically removing the portion of theimbedded anaerobic bacteria from the gingival tissue, and theadministering of the colloidal hydrogen peroxide to the periodontalpocket, directly applying a commensal bacteria into the sulcus or aperiodontal pocket associated with the gingival tissue tore-colonization the sulcus or the periodontal pocket with the commensalnon-harmful bacteria.